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Home My WebLink About0000 SANDY NECK (4) San 33 - ( 7 UPC 12543 No. 53LOR HASTINGS, MN f Town of Barnstable *Permit# ! EO3 Expires 6 mont from issue ate 00 Regulatory Services Fee Thomas F.Geiler,Director .pRESS f fkMI t Building Division Tom Perry,CBO, Building Commissioner JUL 200 Main Street,Hyannis,MA 02601 f q ' i; www.town.barnstable.ma.us v V �j'" 0ffl' W Fax: 508-790-6230 EXPRESS PERT APPLICATION - RESIDENTIAL ONLY Q �� MI Not Valid without Red X-Press Imprint ,Map/parcel Number O 11 / Property Address [Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address -!ndZo"�F�Vd9� Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor j ® I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) QR/Re-roof(stripping old shingles) All construction debris will be taken to y%e /rrQA�[ ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home rove nt Contrac License is required. SIGNATURE:. Q:Forms:expmtrg Revise071405 The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations ' a 600 Washington Street '�' Boston,NIA 02111 ••`�� www.mass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Pluffibers App licant Information Please Print L.e 'bl Name (Business/Organiza 'on/Individu' : 1/�j"7l y (Q-� Address: City/State/Zip: Phone #: Are you an employer? Check the-appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New constriction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.0 Electrical repairs or additions required.] 3. I am a homem per doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.9@ Roof repairs insurance required.] t . employees. [No workers' 13.❑ Other COMP.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such (Contractors that cbeck this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. If am an employer that is providing workers'compensatdon insurance for my employees. Below is the policy and,pob site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500..00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb under dX pains nd penalties of perjury that the information provided abov ds true and correct Si afore: Date: 62& Phone#: gvg Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): 1.hoard of Health 2.wilding Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector jl 6. Other Contact Person: Phone#: Information and Instructions ,.. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constructon or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or . renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions.shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es) and phone number(s)along with their certificate(s) of insurance. Urnited Liability Companies(1LC)or L im;ted Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pernuts or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 1617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/cia